Provider Demographics
NPI:1619221181
Name:WILLINGMYRE, KEITH (PT)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:WILLINGMYRE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 ROUTE 70 E
Mailing Address - Street 2:SUITE 412
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-2210
Mailing Address - Country:US
Mailing Address - Phone:856-354-2022
Mailing Address - Fax:856-354-2231
Practice Address - Street 1:1415 ROUTE 70 E
Practice Address - Street 2:SUITE 412
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2210
Practice Address - Country:US
Practice Address - Phone:856-354-2022
Practice Address - Fax:856-354-2231
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01037800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist